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Bimalleolar fracture.pptx
- 1. • Acute AnkleFracture Dislocation • Fracture Closed Complete Transverse Displaced Medial and Lateral Malleolus Left secondary to Motor Vehicular Accident • Weber B • Lauge-Hansen SER Stage IV • Dias-Tachdjian Stage SI • AO 44A2.3
- 7. TALOCRURAL ANGLE Assess forfibular shortening Measurement Mortise view Line along the distal tibial plafond articular surface Line joining the tips of both malleoli Interpretation Normal: 83° ± 4° 2 or 8-15° 3 Fibular shortening: >2° difference to the contralateral side
- 8. TALAR TILT MORTISE VIEW Measurementof the angle between the talus and the distal tibia, used in the assessment of: 1. Ankle instability 2. Ankle osteoarthritis Measurement Talar tilt is measured on either AP or mortise view radiographs of the ankle. Talar tilt is the angle between the articular surface of the talar dome and the articular surface of the tibial plafond. Interpretation Normal values <2° on non-stress radiographs <5° on inversion stress radiographs Talar tilt ≥2° upgrades Kellgren and Lawrence ankle OA from grade 3a to 3b, which is associated with worse clinical outcomes
- 9. MORTISE VIEW Mortise jointspace should uniformly: < 4mm Lateral Clear Space: <3-6mm Distal tibiofibular overlap >1mm Fibular fossa: Visible AP VIEW Distal tibio-fibular joint: < 5.5mm Distal tibofibular overlap: >6mm Equal Horizontal and Medial CS: 3mm
- 10. MORTISE VIEW Mortise jointspace should uniformly: < 4mm Lateral Clear Space: <3-6mm Distal tibiofibular overlap >1mm Fibular fossa: Visible AP VIEW Distal tibio-fibular joint: < 5.5mm Distal tibofibular overlap: >6mm Equal Horizontal and Medial CS: 3mm
- 11.
- 14. PLAN PLAN: Debridement ankleleft, Closed vs Open reduction multiple pinning lateral and medial malleolus left Lined up as STAT CASE LABORATORIES: HEM: 12.8 WBC: 22.2 PLAT: 310 ESR: 120 CRP:140 Covid 19 PT-PCR negative (+)Covid positive exposure 11-10-22
- 15. PHYSIS Distal tibial physis •Contributes 45% of the growth of the tibia • Ossifies between 6 and 12 months of Age • medial malleolus appears at 7 years in girls and 8 years in boys. • The medial malleolus usually ossifies as a down ward extension of the distal tibial ossific nucleus • The distal aspect of the tibia is completely ossified by 14 to 15 years of age and fuses with the diaphysis at 18 years Distal fibula • Ossifies during the second year of life, generally between the ages of 18 and 20 months. • This physis usually closes 12 to 24 months later than the distal tibial physis CHAPTER 30 Lower Extremity Injuries, pg1379 Tachdjian’s Pediatric Orthopaedics 6th ED
- 16. ANATOMY Ankle Syndesmosis • InterosseousLigament • Anterior and Posterior Inferior Tibiofibular Ligaments • Inferior Transverse Ligament Posteriorly
- 17. Medial Ligamentous Structure Deltoidligament Superficial • Anterior Talotibial Ligament • Posterior Talotibial Ligament • Tibionavicular Ligament • Calcaneotibial Ligament Deep • Primary restraint to lateral displacement of talus
- 18. LATERAL LIGAMENTOUS STRUCTURE •Anterior Talofibular Ligament (ATFL) • Calcaneofibular Ligament (CFL) • Posterior Talofibular Ligament (PTFL)
- 19. Type I andII: • Often amenable to closed tx • Lower risk of physeal arrest Type III and IV: • More likely to require operative tx • Higher risk of physeal arrest Classification (Anatomic) Salter-Harris Classification High interobserver correlation Correlated with outcomes
- 20. CLASSIFICATION (MECHANISTIC) DIAS-TACHDJIAN (1978) 4Types A. Supination-inversion B. Pronation-eversion external rotation (PEER) C. Supination-external rotation D. Supination- plantarflexion
- 21. SUPINATION INVERSION Grade 1:Adduction or inversion force avulses fibula • SH type I or II, rarely can be an epiphyseal fracture Grade 2: Further inversion tibia fracture • Compressive force to medial malleolus • SH type III or IV
- 22. VARIANTS OF GRADEII SUPINATION– INVERSION INJURIES A: SH type I fracture of the distal tibia and fibula. B: SH type I fracture of the fibula, type II tibial fracture. C: SH type I fibular fracture, type III tibial fracture D: SH type I fibular fracture, type IV tibial fracture
- 23. SUPINATION INVERSION • McFarlandFracture • Higher likelihood of nonunion Intra-articular fracture • Delayed union not uncommon • Late displacement can occur • Growth arrest most common in this pattern Up to 40-50% • Adequacy of reduction is only predictive factor of physeal arrest
- 24. PRONATION-EVERSION, EXTERNAL- ROTATION • Thisinjury results when an eversion and lateral rotation force is applied to a fully pronated foot • Tibial SH I/II fracture pattern • Thurston-Holland fragment posterolateral • Transverse fibula fracture • Can be a greenstick fracture • Premature physeal closure is common
- 25. Supination-External Rotation Grade 1: •External rotational force • SH type II tibia fracture • Thurston Holland fragment visible on AP Xray • Differentiates from Supination- plantarflexion • Tibial epiphysis displaces posterolaterally • Similar to Supination-plantarflexion Grade 2: • Spiral fx distal fibula metaphysis • Anteroinferior to posterosuperior • Complications: • External rotation deformity can occur due to incomplete reduction
- 26.
- 27. COTTON FRACTURE Cotton fractureis a three-part fracture of the ankle involving the lateral malleolus, medial malleolus and distal posterior aspect of the tibial plafond (posterior malleolus)
- 28. TREATMENT A. Location offracture B. Amount of displacement C. Age of child (how much growth remains) D. Distal tibia physis contributes: • 3-4 mm growth per year • 35-45% of overall tibia length • Follow up X-rays for 6-12 months to evaluate for physeal closure
- 29. NON-OPERATIVE • SLCC for4 weeks • Weight bearing is restricted for initial 2 weeks • Additional immobilization is based on amount of healing present
- 30. OPERATIVE INDICATIONS • Openfractures or injuries with severe soft tissue injury • Displacement of the articular surface (>2mm) • Unable to obtain or maintain acceptable reduction
- 31.
Editor's Notes
- #16 Distal tibial physis Contributes 45% of the growth of the tibia Ossifies between 6 and 12 months of Age medial malleolus appears at 7 years in girls and 8 years in boys. The medial malleolus usually ossifies as a down ward extension of the distal tibial ossific nucleus The distal aspect of the tibia is completely ossified by 14 to 15 years of age and fuses with the diaphysis at 18 years Distal fibula Ossifies during the second year of life, generally between the ages of 18 and 20 months. This physis usually closes 12 to 24 months later than the distal tibial physis
- #18 Because ligamentous structures are stronger than the physis in children, avulsion-type injuries, in which traumatic forces exerted through the ankle ligaments create physeal ractures, are common.
- #19 Because ligamentous structures are stronger than the physis in children, avulsion-type injuries, in which traumatic forces exerted through the ankle ligaments create physeal ractures, are common.
- #25 This injury results when an eversion and lateral rotation force is applied to a fully pronated foot Typically, a Salter-Harris type I or II fracture of the distal tibia occurs, together with a transverse or short oblique fibular fracture located 4 to 7 cm proximal to the tip of the lateral malleolus Tibial SH I/II fracture pattern Thurston-Holland fragment posterolateral Transverse fibula fracture Can be a greenstick fracture Premature physeal closure is common
- #26 Radiographic appearance of a supination–lateral rotation fracture pattern. The distal tibial fracture begins distolaterally and spirals proximomedially. The distal fibula has sustained a spiral fracture as a result of the external rotation force